Building Biology House Inspection Questionnaire

1. Personal & Contact Details

Please provide your contact details and age for processing the analysis.

Full Name * Address (Street, House No., Zip Code, City, Country) *

Email Address *

Phone Number *

Age *

2. Location Description

(If applicable: Type, strength, distance from the house?)

High-voltage power line Transformer station Mast on roof or underground cabling Railway line VHF/TV/Radar/Mobile (cell) phone transmitter Factory/Landfill/Street (main traffic/residential/side street) Pure residential area / Commercial and residential area Population/Building density Orientation of sleeping and living areas (cardinal direction)

3. Details on the House / Apartment

Year of construction 1-, 2-, Multi-family house / Floors Sleeping place: On which floor? Duration of stay (Since when have you lived in this house?) Renovation (when? what?)

Building Type Details

Construction Method

Brick construction with concrete ceilings Solid construction (full concrete) Wood frame construction / Log house

Roof material / Insulation Cellar (Is the cellar inhabited / insulated?) Further notes on building type

4. Electrics - Low Frequency

Wiring (sheathed cable, flat cable, shielded?) Fuses (RCD/Circuit breakers available?) Electrical devices in/near the sleeping area Low-voltage/Halogen lighting / Dimmers (Where are they located?) Mains disconnect switches / Line filters (Available?)

5. Electrics - High Frequency & Radio

WLAN Router (Where? Switched off at night?) DECT Telephone (Where? In the bedroom?) Smart Meter / Photovoltaic (PV) system / Induction cooktop Existing measurements (if available)

6. Moisture & Mold

Was there water damage (When? Where? How resolved?) Visible mold/mold odor (Where? Since when?) Problems with building insulation (cold bridges, condensation)?

7. Pollutants & Odors

Unknown odors (e.g. sweet, foul, chemical)? Newly introduced materials (paints, floors, furniture, carpets) in the last 2 years? Chemical treatments (wood preservation, pesticides, preservatives)? Vermin or pests (e.g. mice, ants, woodworms)? Further notes on pollutants (e.g. asbestos, radon knowledge)

8. Health Complaints

Please check the applicable symptoms and indicate the severity. (CRUCIAL for the analysis!)

X no complaints

+ minor complaints

++++ increasing/critical complaints

Symptom

Severity

Context / Notes (e.g. In summer/winter)

Additional Questions

Have you noticed negative changes in pets or plants? Do you notice an improvement in your health condition in other locations (e.g. on vacation, in a hotel)? Diagnosis from the doctor or non-medical practitioner:

Important note on completion:

1. After clicking the button, the print view will open. **Save the questionnaire as a PDF** before proceeding. 2. You can then be redirected to the secure payment via the unlocked button.